Child Welfare Licensed Facility Forms and Publications Group Home, Residential Care Center, Shelter Care, Child Placing Agency The Department of Children and Families (DCF) has created a number of forms and publications for group homes, residential care centers, shelter care, and child placing agencies. Some, but not all, of these forms are mandatory. These forms and publications can be found below and are searchable by facility type. To view forms and publications for a facility type, chose the facility from the drop-down menu below. F/P? F=Forms and P=Publications. Publications do not have a status. Click on the sort arrows next to the columns to help find the documents you need. Use the selection list below to find all the forms for a specific facility type. Select Facility Type Child Placing Agency(CPA) Group Home(GH) Shelter Care (SC) Residential Care Center (RCC) Form/Publication Name Number Status File Format F/P? Key External Agency Agreement on Access to SYNC For Accessing Agency (Licensed Facility) DCF-F-5618-E Mandatory Word F GH, RCC External Agency Agreement on Access to SYNC For Accessing Agency (Licensed Facility) DCF-F-5618 Mandatory PDF F/P GH, RCC Qualified Residential Treatment Program Certification Application DCF-F-5474-E Mandatory Word F GH, RCC, SC Qualified Residential Treatment Program Continuation Application DCF-F-5475-E Mandatory Word F GH, RCC, SC Caregiver Background Checks Substantially Related Investigation Report for Child Welfare Agencies DCF-F-5160-E Voluntary Word F GH, RCC, SC, CPA Fire Safety Inspection - Shelter Cares DCF-F-4147-E Voluntary PDF F SC Reasonable Prudent Parenting Decision Record DCF-F-5124-E Mandatory Word F GH, RCC, SC, CPA Child Welfare Vehicle Safety Inspection DCF-F-4148-E Mandatory Word F GH, RCC, SC, CPA Reasonable and Prudent Parenting Standard Review DCF-F-5123-E Voluntary Word F GH, RCC, SC, CPA Adoption Assistance Agreement DCF-F-CFS0074-E Mandatory Word F CPA Adoptive Family Placement Agreement DCF-F-CFS00140 Mandatory PDF F CPA Adoptive Placement Checklist - Child Placing Agency - Domestic DCF-F-CFS2259 Voluntary Word F CPA Adoptive Placement Checklist - Child Placing Agency International DCF-F-CFS2155 Voluntary Word F CPA Affidavit - A birth parent's consent to allow contact information to be given to their adult adopted child. DCF-F-CFS0142-E Voluntary Word F CPA Affidavit - A birth parent's consent to allow contact information to be given to their adult adopted child. DCF-F-CFS0142-E-H (Hmong) Voluntary PDF F CPA Affidavit - A birth parent's consent to allow contact information to be given to their adult adopted child. DCF-F-CFS0142-E-S (Spanish) Voluntary PDF F CPA Amendment Request to Extend Care to Residents 18 Years of Age and over, but under 21 DCF-F-5081 Mandatory PDF F GH, RCC, SC, CPA Application to DCF Exceptions Panel for Exception to Ch. DCF 56 DCF-F-CFS0847-E Mandatory PDF F GH, RCC, SC, CPA Assessment Plan - Group Home DCF-F-5377-E Voluntary Word F GH Assessment and Discharge Summary - Respite Group Homes DCF-F-2831 Voluntary Word F GH Treatment Plan - Group Home DCF-F-CFS2430-E Voluntary Word F GH Assessment and Treatment Plan - Residential Care Centers for Children and Youth DCF-F-2440 Voluntary Word F RCC Background Check Information Schedule – Child Placing Agencies DCF-P-PFS4075D PDF P CPA Background Check Information Schedule Group Home, Shelter Care, and Residential Care Centers for Children and Youth DCF-P-PFS4075C PDF P GH, RCC, SC Background Information Disclosure (BID) DCF-F-2978-E Mandatory Word F GH, RCC, SC, CPA Background Information Disclosure (BID) DCF-F-2978-E-S (Spanish) Mandatory Word F GH, RCC, SC, CPA Background Information Disclosure (BID) DCF-F-2978-E-H (Hmong) Mandatory Word F GH, RCC, SC, CPA Child Foster Care Licensing Checklist DCF-F-CFS0787 Mandatory Word F CPA Child Placing Agency Foster Child Record Checklist DCF-F-CFS0380 Voluntary Word F CPA Child Record - Shelter Care Facilities DCF-F-CFS2389-E Voluntary Word F SC Child Record Checklist - Group Homes DCF-F-CFS0379 Voluntary Word F GH Child Record Checklist - Shelter Care Facilities DCF-F-CFS2414 Voluntary Word F SC Child Welfare Applicant/Licensee Rights and Responsibilities DCF-P-2498 PDF P GH, RCC, SC, CPA Child Welfare Continuing Education Record - Independent Reading/Video Viewing DCF-F-5378-E Voluntary Word F GH, RCC, SC, CPA Child Welfare Request for Exception DCF-F-5023-E Mandatory Word F GH, RCC, SC, CPA Child Welfare Request for Exception - Age DCF-F-5085 Mandatory Word F GH, RCC, SC Community Advisory Committee Documentation DCF-F-CFS0367-E Mandatory Word F GH, RCC Community Living Arrangements DCF-P-5106 PDF P GH, RCC DCF 12 Negative Action Notice DCF-F-CFS2191 Voluntary PDF F CPA Discharge Summary - Group Home DCF-F-5379-E Voluntary Word F GH Email Subscription Service DCF-P-5107-H (Hmong) PDF P GH, RCC, SC, CPA Email Subscription Service DCF-P-5107-S (Spanish) PDF P GH, RCC, SC, CPA Email Subscription Service DCF-P-5107 PDF P GH, RCC, SC, CPA Fire Safety and Emergency Response Documentation - Group Homes DCF-F-CFS2384 Voluntary PDF F GH Fire Safety and Emergency Response Documentation - Residential Care Centers for Children and Youth DCF-F-CFS2383 Voluntary PDF F RCC Fire Safety and Emergency Response Documentation - Shelter Care Facility DCF-F-CFS2385 Voluntary PDF F SC Fire Safety Inspection - Group Homes DCF-F-CFS0909 Voluntary Word F GH Fire Safety Inspection - Residential Care Centers DCF-F-CFS0357 Voluntary PDF F RCC Foster Home Agreement Child Placed In Out-of-Home Care by Agency DCF-F-CFS0107-E Mandatory Word F CPA Foster Home Information for WiSACWIS DCF-F-CFS2386 Mandatory Word F CPA, Foster Foster Home Licensure Notification DCF-F-CFS2187-E Voluntary PDF F CPA Foster Home Record Checklist - Child Placing Agencies DCF-F-CFS0381 Voluntary Word F CPA Foster Parent Insurance Program Claim of Loss or Damage DCF-F-CFS0116 Mandatory PDF F CPA Foster Parent Insurance Program Damage Claim Checklist DCF-F-CFS2198-E Voluntary Word F CPA, FC Foster Parent Insurance Program Verification of Claims DCF-F-CFS0117-E Mandatory PDF F CPA How to Access Forms for Child Welfare Facilities DCF-P-PFS4098 PDF P GH, RCC, SC, CPA ICPC Placement Request DCF-F-CFS0100A Mandatory Word F GH, RCC, SC, CPA ICPC Report on Child's Placement Date or Change of Placement DCF-F-CFS0100B Mandatory Word F GH, RCC, SC,, CPA Out-of-Home Care Providers - Part A CFS0872A Mandatory Word F GH, RCC, SC, CPA Out-of-Home Care Providers - Part B CFS0872B Mandatory Word F GH, RCC, SC, CPA Intake Information - Group Home Resident DCF-F-CFS2382A-E Voluntary Word F GH Intake Information - Group Home Resident Under 6 Years of Age DCF-F-CFS2382B-E Voluntary Word F GH It Shouldn't Hurt to be a Child DCF-P-PFS0101 PDF P GH, RCC, SC, CPA It Shouldn't Hurt to be a Child: Ser niño no debería doler DCF-P-PFS0101S (Spanish) PDF P GH, RCC, SC, CPA It Shouldn't Hurt to be a Child: Ua ib tug me nyuam yuav tsum tsis txhob raug mob DCF-P-PFS0101H (Hmong) PDF P GH, RCC, SC, CPA Licensing Checklist - Child Placing Agencies DCF-F-CFS0362 Mandatory Word F CPA Licensing Checklist - Group Homes DCF-F-CFS0358 Mandatory Word F GH Licensing Checklist - Residential Care Centers DCF-F-CFS0354 Mandatory Word F RCC Licensing Checklist - Shelter Care Facilities DCF-F-CFS0361 Mandatory Word F SC Medical Services Consent DCF-F-CFS0997 Voluntary PDF F CPA Medical Services Consent DCF-F-CFS0997-H (Hmong) Voluntary PDF F GH, RCC, SC, CPA Medical Services Consent DCF-F-CFS0997-S (Spanish) Voluntary PDF F GH, RCC, SC, CPA Medical Services Consent - Child Welfare Facilities DCF-F-CFS2379-E Voluntary Word F GH, RCC, SC, CPA Medication Administration Record - Group Homes for Children DCF-F-CFS2338 Voluntary Word F GH Notice to Foster Parents Regarding Confidentiality of Records DCF-F-CFS2186 Voluntary PDF F CPA Notice to Foster Parents Regarding Confidentiality of Records: Aviso Para Padres de Crianza en Referencia a la Confidencialidad de los Registros DCF-F-CFS2186S (Spanish) Voluntary PDF F CPA Out-of-Home Placement Notification or Recommended Placement Notification DCF-F-CFS2189 Voluntary PDF F GH, RCC, SC, CPA Personnel Record Checklist - Child Placing Agencies DCF-F-CFS0369 Voluntary PDF F CPA Personnel Record Checklist - Group Homes DCF-F-CFS0383 Voluntary Word F GH Personnel Record Checklist - Shelter Care Facilities DCF-F-CFS2399 Voluntary Word F SC Personnel Requirements - Child Placing Agency DCF-P-2913 PDF P CPA Personnel Requirements - Group Homes for Children DCF-P-PFS4100 PDF P GH Policy/Procedure Checklist - Child Placing Agency DCF-F-2850-E Voluntary Word F CPA Policy/Procedure Checklist - Group Homes for Children DCF-F-CFS2378 Voluntary Word F GH Policy/Procedure Checklist - Shelter Care DCF-F-5380-E Voluntary Word F SC Proposed Rate Request DCF-F-2696-E Word F GH, RCC, CPA Rate Regulation DCF-P-5108-S (Spanish) PDF P GH, RCC, CPA Rate Regulation DCF-P-5108 PDF P GH, RCC, CPA Rate Regulation DCF-P-5108-H (Hmong) PDF P GH, RCC, CPA Reference Check - Group Home DCF-F-5381-E Voluntary Word F GH Request by Shelter Care Facility to Accept Voluntary Placements and/or to Provide Respite Care Services DCF-F-5041-E Mandatory Word F SC Resident Orientation Documentation - Group Homes DCF-F-CFS2381-E Voluntary PDF F GH Resident Record Checklist - Residential Care Centers for Children and Youth DCF-F-CFS2139-E Voluntary Word F RCC Residential Care Center Child Abuse and Neglect Reporting and Confidentiality Responsibilities DCF-F-CFS2172 Mandatory PDF F RCC Residential Care Center General Personnel Record Checklist DCF-F-CFS2140 Voluntary Word F RCC Policy/Procedure Checklist - Residential Care Centers DCF-F-CFS2168 Voluntary Word F RCC Residential Care Center Statutorily Reportable Death DCF-F-CFS2183 Mandatory Word F RCC Rights of Minors in Inpatient Community Mental Health Facilities P-20470A PDF P GH, RCC, SC, CPA Sanitation Checklist - Residential Care Centers DCF-F-CFS0353 Voluntary PDF F RCC Serious Incident Report DCF-F-CFS2146-E Mandatory PDF F GH, RCC, SC, CPA Staff / Volunteer Orientation Documentation - Group Homes DCF-F-CFS2380-E Voluntary PDF F GH Staff Continuing Education and Training Record Child Welfare Programs DCF-F-CFS2142 Voluntary PDF F GH, RCC, SC, CPA Staff Health Report - Child Welfare Facilities DCF-F-CFS0384 Voluntary PDF F GH, RCC, SC Treatment Plan Review - Group Home DCF-F-5382-E Voluntary Word F GH Use of 10+ Passenger Vans To Transport Children To and From Schools DCF-P-PFS4088 PDF P GH, RCC, SC, CPA Voluntary Placement Agreement DCF-F-CFS1590 Mandatory Word F GH, RCC, SC, CPA Voluntary Placement Agreement DCF-F-CFS1590-H (Hmong) Mandatory Word F GH, RCC, SC, CPA Voluntary Placement Agreement DCF-F-CFS1590-S (Spanish) Mandatory Word F GH, RCC, SC, CPA Voluntary Placement Agreement for Shelter Car DCF-F-5040-E-S (Spanish) Mandatory PDF F SC Voluntary Placement Agreement for Shelter Care DCF-F-5040-E Mandatory Word F SC Adoption Assistance Agreement DCF-F-CFS0074-E-H (Hmong) Mandatory PDF F CPA Adoption Assistance Agreement DCF-F-CFS0074-E-S (Spanish) Mandatory PDF F CPA Rehabilitation Review Application Instructions DCF-F-419 Mandatory PDF F GH, RCC, SC, CPA Rehabilitation Review Application Instructions DCF-F-419-H (Hmong) Mandatory PDF F GH, RCC, SC, CPA Rehabilitation Review Application Instructions DCF-F-419-S (Spanish) Mandatory PDF F GH, RCC, SC, CPA Disaster Plan DCF-F-5129-E Mandatory Word F GH, RCC, SC Communication Log DCF-F-5276-E Voluntary Word F GH, RCC, SC Target Groups DCF-F-5207-E Mandatory Word F GH, RCC, SC Acknowledgment: Receipt of Adoption Assistance Information DCF-F-2672-E Mandatory Word F CPA Acknowledgment: Receipt of Adoption Assistance Information DCF-F-2672-H (Hmong) Mandatory Word F CPA Acknowledgment: Receipt of Adoption Assistance Information DCF-F-2672-S (Spanish) Mandatory Word F CPA Resident Care Staff Qualifications and Observation Log DCF-F-5298-E Voluntary Word F GH Child Welfare Licensing Shelter Care Extension DCF-F-2601-E Voluntary Word F SC
